Periodontal Disease Risk Assessment Form
Patient Information
Name
Age
Gender
Female
Male
Other
Medical History
Diabetes
Yes
No
Smoking
Yes
No
Former
Immunosuppression
Yes
No
Dental History
Gum Bleeding
Yes
No
Tooth Mobility
Yes
No
Pocket Depth (mm)
Known Bone Loss
Yes
No
Oral Hygiene
Brushing Frequency (per day)
Interdental Cleaning
Yes
No
Family History
Periodontal Disease in Family
Yes
No
Unknown
Comments / Notes